DRG Validation Auditor

Join Our Team as a Remote DRG Validation Auditor

Are you a meticulous and experienced healthcare auditor with a passion for ensuring accurate coding and reimbursement? We’re looking for a talented DRG Validation Auditor to join our innovative team. This is a remote opportunity to contribute to the cutting edge of healthcare technology and make a real difference in improving data quality and medical coding practices.

About the Role

As a key member of our team, you’ll collaborate with clinicians, engineers, product managers, and other domain experts to enhance our state-of-the-art machine learning software. Your expertise will help shape the next generation of auditing tools and contribute to a dynamic and high-performing environment.

This role requires a strong foundation in both inpatient and outpatient coding/auditing, with a specific focus on:

• Inpatient MS-DRG/APR-DRG
• Outpatient CPT-4/HCPCS coding and auditing
• Extensive experience in pediatric healthcare services and coding accuracy
• Payer claim processing

Key Responsibilities

• Validate the accuracy of ICD-10-CM, ICD-10-PCS, DRG, APR groups, CPT and HCPCS codes for both inpatient and outpatient claims.
• Audit inpatient claims to identify potential over-assigned DRG codes, ensuring accurate reimbursement following regulatory and contractual guidelines.
• Identify and resolve intricate coding discrepancies.
• Communicate complex coding findings to the project lead and cross-functional teams.
• Maintain the confidentiality, integrity, and availability of protected health information in compliance with HIPAA security policies.

Essential Qualifications

• Extensive knowledge of the healthcare industry, including coding, billing, auditing, compliance, and reimbursement for both inpatient and outpatient facility settings.
• Significant experience with pediatric inpatient facility settings.
• At least 5 years of experience auditing facility inpatient and outpatient services with DRG and APR-DRG expertise, with familiarity in clinical documentation improvement (CDI) practices.
• Comprehensive understanding of current Official Coding Guidelines and Coding Clinic citations.
• Proven ability to contribute to cost reduction strategies through accurate claims payment and appropriate diagnosis-related group (DRG) assignment.
• Familiarity with inpatient denial coding systems (e.g., CARC codes).
• Proficiency in coding software, electronic health record systems, and AI-powered tools for DRG assignment.
• Exceptional knowledge of anatomy, physiology, disease processes, and pharmacology.
• Detail-oriented with a deadline-driven approach.
• Strong critical thinking and problem-solving skills.
• Excellent organizational skills, accountability, and a proactive work ethic.

Certification Requirements

Candidates must possess one of the following certifications:

• RHIA, RHIT, or CCS from AHIMA
• CPMA, CIC, COC from AAPC

Ideal Candidate Attributes

We are looking for individuals who embody the following attributes:

• Humble: Committed to continuous learning, adapting, and improvement. Open to feedback and recognizing the contributions of others.
• Supportive: Empowers and uplifts teammates, listens actively, and prioritizes the well-being and growth of others.
• Driven: Self-motivated to achieve ambitious goals, takes initiative, and demonstrates confident decision-making.
• Transparent: Aligned with a culture of openness, integrity, and trustworthiness. Follows through on commitments and values accountability.
• Innovative: Entrepreneurial spirit with a scrappy mentality. Pursues potential and finds creative solutions.

Additional Information

Work volumes will vary based on project demands.

AAPC Services is an Equal Opportunity Employer and values diversity at all levels. We do not discriminate based on race, sex, age, disability, religion, national origin, or any other protected basis.